Endovascular stroke treatment today

The purpose of this study was to review current treatment options in acute ischemic stroke, focusing on the latest advances in the field of mechanical recanalization. These devices recently made available for endovascular intracranial thrombectomy show great potential in acute stroke treatments. Compelling evidence of their recanalization efficacy comes from current mechanical embolectomy trials. In addition to allowing an extension of the therapeutic time window, mechanical recanalization devices can be used without adjuvant thrombolytic therapy, thus diminishing the intracranial bleeding risk. Therefore, these devices are particularly suitable in patients in whom thrombolytic therapy is contraindicated. IV and IA thrombolysis and bridging therapy are viable options in acute stroke treatment. Mechanical recanalization devices can potentially have a clinically relevant impact in the interventional treatment of stroke, but at the present time, a randomized study would be beneficial.     

Clinical MRI of acute ischemic stroke

The most important service that imaging provides to patients with ischemic stroke is to rapidly identify those patients who are most likely to benefit from immediate treatment. This group includes patients who have severe neurological symptoms due to an occlusion of a major artery, and who are candidates for recanalization using intravenous thrombolysis or intra-arterial intervention to remove the occlusion. Outcomes for these patients are determined by symptom severity, the artery that is occluded, the size of the infarct at the time of presentation, and the effect of treatment. MRI provides key physiological information through MR angiography and diffusion MRI that has been proven to be of high clinical value in identify patients who are in need of immediate treatment. Perfusion MRI provides information about the ischemic penumbra, but its clinical value is unproven. In current clinical practice, the time since stroke onset is dominant over physiologic information provided by MRI in treatment decisions. This will change only when clinical trials prove that stroke physiology as revealed by MRI is superior to time from stroke onset in promoting good clinical outcomes.     

Combined intraarterial/intravenous thrombolysis for acute ischemic stroke

BACKGROUND AND PURPOSE: The intravenous use of recombinant tissue-type plasminogen activator (rTPA) in acute ischemic stroke has been investigated in three large trials. Limited series have reflected outcome after local intraarterial thrombolysis (LIT) in the cerebral territory. The purpose of this study was to evaluate the safety and efficacy of combined intraarterial/intravenous thrombolysis using rTPA (actilyse) for acute ischemic stroke. METHODS: Forty-five patients with acute onset of severe hemispheric stroke and without signs of major cerebral infarction on early CT scans were randomized by order of admission. Twelve patients were treated with 50 mg actilyse (maximal dose, 0.7 mg/kg); three had occlusion of the internal carotid artery and nine had occlusion of the middle cerebral artery. Thrombolysis was started by LIT and continued intravenously within 6 hours of stroke onset. Outcome, assessed after 1 and 12 months according to the modified Rankin scale (MRS), was considered good (MRS score, 0-3) for patients who were functionally independent and poor (MRS score, 4-5) for those who were dependent or had died. RESULTS: In the thrombolysis group, outcome was good in eight patients at 1 month and in 10 patients at 12 months; in the control group, outcome was good in seven (21%) and 11 (33%) patients, respectively. Of the eight patients with a good outcome after thrombolysis, four had complete and one had partial recanalization. In the control group, the rate of intracerebral hemorrhage was 6%. Mortality at 1 month in the thrombolysis and control groups was 17% and 48%, respectively. CONCLUSIONS: Combined intraarterial/intravenous thrombolysis with low-dose rTPA may be a safe and effective treatment for acute ischemic stroke within 6 hours in carefully selected patients.     

MR imaging-guided intravenous thrombolysis in posterior cerebral artery stroke

PCA stroke was under-represented in or excluded from the clinical trials examining thrombolysis based on the PWI-DWI mismatch concept. We present 6 patients with PCA stroke treated with thrombolysis in an extended time window by using MR imaging criteria. Symptoms included aphasia, sensorimotor hemiparesis, hemineglect, and homonymous hemianopia. Initial MR imaging demonstrated circumscribed ischemic lesions in the thalamus or hippocampus; MR angiography showed PCA occlusion with corresponding hypoperfusion. Follow-up MR imaging showed partial/complete recanalization in 4 patients with minor infarction growth, while in 1 patient, PCA occlusion persisted, resulting in a large PCA infarction. Three patients improved within 2 hours; at discharge, homonymous hemianopia had resolved in 3 patients. At 3-month follow-up, 4 patients had an mRS score of 0 or 1. These results support the approach to treat patients with PCA stroke with thrombolysis based on the mismatch concept. Because rehabilitation options for hemianopia are limited, thrombolysis may enhance the chance of a favorable outcome.     

Hyperacute therapy of ischemic stroke: intravenous thrombolysis

Stroke is the third most common cause of death in the United States following heart disease and cancer. Following the success of thrombolysis for myocardial infarction in the early 1990s, major trials for evaluation of this new therapeutic approach for ischemic stroke were initiated. The majority of ischemic strokes are due to occlusion of a cerebral vessel by a blood clot. Occlusion of a cerebral blood vessel leads to a core of infracted tissue surrounded by a relatively hypoperfused but viable brain tissue (the ischemic penumbra), which can be potentially salvaged by rapid recanalization of the target vessel. The underlying rationale for introduction of thrombolytic drugs is the lysis of an obliterating thrombus and reestablishment of blood flow. In this article we review the major intravenous thrombolysis trials leading to approval of intravenous recombinant tissue plasminogen activator, the only FDA approved treatment available today for acute ischemic stroke.     

Non-traumatic vascular emergencies: management of occluded hemodialysis shunts and venous access

Shunt thrombosis is a relatively frequent complication of implant grafts but less common in native fistulas; both may undergo mechanical recanalization without thrombolysis. While in native fistulas, simple balloon angioplasty is a very useful tool for short-segment thrombosis, extensive thrombosis in native veins or grafts requires use of different mechanical devices or aspiration catheters. In venous access thrombosis, thrombolysis or fibrinous sheath stripping are percutaneous options. Electronic Publication     

多模式MRI指导的超急性期缺血性脑卒中静脉溶栓治疗

2008

磁共振多模式快速成像指导缺血性脑卒中溶栓八例 [其它论文] -中华神经科杂志2008

2.0.TX;2-J.aspx'>Treatment of acute ischemic stroke [其它论文] 2000

Extending the time window for thrombolysis:evidence from acute stroke trials 2005

The evolving role of acute stroke imaging in intravenous thrombolytic therapy:patient selection and outcomes assessment 2005

Schellinger PD.Thomalla G.Fiehler J MRI-basod and CTbased thrombolytic therapy in acute stroke within and beyond established time windows:an analysis of 1210 patients [其它论文] 2007

卫生部疾病控制司.中华医学会神经科学会 中国脑血管病防治指南 2005

Thomalla G.Schwark C.Sobesky J Outeome and symptomatic bleeding complications of intravenous thrombolysis within 6 hours in MRI-selected stroke patients:comparison of a german multicenter study with the pooled data of ATLANTIS,ECASS and NINDS rt-PA trials [其它论文] 2006

Warach S.Dashe JF.Edelman RR Clinical outcome in iachemic stroke predicted by early diffusion-weighted and perfusion magnetic resonance imaging:a preliminary analysis 1996

Barber PA.Darby DG.Desmond PM Prediction of stroke outcome with echoplanar perfusion-and diffusion-weighted MRL 1998

薛静.高培毅.林燕 MR血管成像在急性缺血性脑卒中溶栓治疗中的价值 [其它论文] -中华放射学杂志2008

Donnan GA.Howells DW.Markus R Can the time window for administration of thrombolyties in stroke be increased? 2003

>>更多...     

Use of self-expanding intracranial stents in the treatment of acute ischemic stroke

Conventional endovascular therapy for acute ischemic stroke includes intraarterial pharmacologic thrombolysis with tissue plasminogen activator (TPA) administration with or without mechanical thrombectomy with a variety of devices. The present report describes two cases of stroke refractory to TPA administration in which successful recanalization was accomplished by the use of a self-expanding intracranial stent. Stent-assisted recanalization may be a viable option for patients with acute ischemic stroke refractory to thrombolysis or thrombectomy.     

Diffusion-weighted MR imaging of an acute venous stroke: case report.

A patient with a superior sagittal sinus thrombosis had progressively worsening symptoms and signs that resolved after IV heparin therapy. MR imaging revealed abnormalities in diffusion, similar to those seen with acute arterial stroke. Abnormalities shown on a T2-weighted fast spin-echo and fluid-attenuated inversion recovery images resolved completely. The findings in this report contradict those from previous reports that suggest diffusion-weighted imaging with quantitative apparent diffusion coefficients may be used in selecting patients for dural venous sinus thrombolysis.     

Transhepatic catheter-directed thrombectomy and thrombolysis of acute superior mesenteric venous thrombosis

PURPOSE: To evaluate clinical outcomes after percutaneous treatment of superior mesenteric vein (SMV) thrombosis. MATERIALS AND METHODS: A retrospective chart review was conducted of all patients with SMV thrombosis treated with percutaneous catheter-directed thrombectomy/thrombolysis. The demographics of the study population, potential causative factors contributing to SMV thrombosis, and morbidity and mortality associated with therapy were assessed. RESULTS: Eleven patients (mean age, 44.3 years +/- 12.8) with SMV thrombosis were treated with percutaneous transhepatic catheter-directed thrombectomy/thrombolysis. Potential causative factors included recent major abdominal surgery, thrombophilic conditions, pancreatitis, and repetitive abdominal trauma. The mean duration between the onset of symptoms and percutaneous treatment was 8.6 days +/- 6.5. Computed tomography confirmed the clinical diagnosis in nine patients (81.8%). One patient (9.1%) had a bleeding complication, which was treated by chest tube drainage without long-term sequelae. One patient (9.1%) with refractory SMV thrombosis died of sepsis and multiple organ failure. No recurrent episode of SMV thrombosis or mortality was documented during a mean follow-up of 42 months +/- 22.5. CONCLUSIONS: Percutaneous transhepatic catheter-directed thrombectomy/thrombolysis for SMV thrombosis is associated with a rapid improvement in symptoms and low incidences of long-term morbidity and mortality. Percutaneous thrombectomy and thrombolysis should be considered in all patients with acute SMV thrombosis without evidence of bowel necrosis.     

介入溶栓治疗下肢深静脉血栓的效果评价及预后影响因素分析

目的分析介入溶栓治疗下肢深静脉血栓（DVT）的临床效果及影响预后的相关因素。 方法回顾性分析2012年7月—2015年6月收治的65例DVT形成患者的临床资料,男27例,女38例,平均年龄59.9岁,其中予单纯药物治疗16例、药物+置管溶栓治疗23例、药物+置管溶栓+机械溶栓联合治疗26例;44例患者行滤器置入术。 结果65例患者经治疗后,截止随访治疗有效52例,无效及复发13例,平均住院时间16.2 d,围手术期死亡0例。Logistic回归分析显示疾病病程和治疗方法是影响DVT预后的影响因素,多元回线性归分析显示住院时间与病程、血栓解剖位置、滤器有线性回归关系（P<0.05）。 结论疾病病程和治疗方法是影响DVT患者预后的影响因素,病程、血栓解剖位置、治疗方法及滤器是影响住院时间的因素,早期合适的诊治,可降低DVT的再发及并发症。     

Acute stroke magnetic resonance imaging: current status and future perspective

Cerebral stroke is one of the most frequent causes of permanent disability or death in the western world and a major burden in healthcare system. The major portion is caused by acute ischemia due to cerebral artery occlusion by a clot. The minority of strokes is related to intracerebral hemorrhage or other sources. To limit the permanent disability in ischemic stroke patients resulting from irreversible infarction of ischemic brain tissue, major efforts were made in the last decade. To extend the time window for thrombolysis, which is the only approved therapy, several imaging parameters in computed tomography and magnetic resonance imaging (MRI) have been investigated. However, the current guidelines neglect the fact that the portion of potentially salvageable ischemic tissue (penumbra) is not dependent on the time window but the individual collateral blood flow. Within the last years, the differentiation of infarct core and penumbra with MRI using diffusion-weighted images (DWI) and perfusion imaging (PI) with parameter maps was established. Current trials transform these technical advances to a redefined patient selection based on physiological parameters determined by MRI. This review article presents the current status of MRI for acute stroke imaging. A special focus is the ischemic stroke. In dependence on the pathophysiology of cerebral ischemia, the basic principle and diagnostic value of different MRI sequences are illustrated. MRI techniques for imaging of the main differential diagnoses of ischemic stroke are mentioned. Moreover, perspectives of MRI for imaging-based acute stroke treatment as well as monitoring of restorative stroke therapy from recent trials are discussed.     

Intracerebral hemorrhage after transcatheter thrombolysis of non-occluding superior mesenteric artery thrombosis

We performed transcatheter thrombolysis on a 64-year-old man with non-occluding superior mesenteric artery (SMA) thrombosis because his severe symptoms could not be controlled with medication. An enhanced computed tomography (CT) scan revealed intramural thrombosis in the SMA. We were concerned that the narrowing of the SMA lumen might progress to complete occlusion, resulting in a high likelihood of mortality. After dissolution of the SMA thrombosis, the original symptoms almost completely disappeared. However, intracranial hemorrhage occurred 8 hr after thrombolysis, requiring surgical intervention. Transcatheter thrombolysis is thought to be a useful treatment for SMA thrombosis, especially in elderly patients with a high operative risk; however, the possibility of intracerebral hemorrhage must be taken into consideration.     

Pancreatitis caused by rheolytic thrombolysis: an unexpected complication

Two patients developed acute pancreatitis after mechanical thrombolysis with use of the AngioJet system. Patient 1 had undergone a remote complex revascularization of the lower extremities and presented with acute ischemia after thrombosis of his composite distal bypass. Patient 2 presented with superior vena cava (SVC) syndrome and had thrombosis of the SVC and innominate veins. Despite dissimilar presentations, both patients had renal insufficiency, were treated with mechanical and chemical thrombolysis, and had extensive thrombus burden. The pathophysiology of acute pancreatitis in this setting is believed to be secondary to massive hemolysis in the presence of chronic renal insufficiency. This phenomenon should be considered in patients whom develop abdominal pain after mechanical thrombolysis.     

肝素在血栓性病变介入溶栓治疗中的作用

目的：探讨肝素在血栓性病变的介入性溶栓抗凝治疗中的作用。方法：急性脑血栓形成22例,四肢动脉血栓18例,髂股静脉血栓200例,下腔静脉血栓20例,分别给以肝素或小分子肝素行全身抗凝。经导管或局部给以溶栓、消融和下腔静脉过滤器放置等治疗,术中和术后也全身使用肝素抗凝治疗。结果：动脉血栓在肝素抗凝下,经导管溶栓疗效肯定,术后必须以肝素抗凝才能保持管腔通畅;髂股静脉血栓形成后完全再通率低于动脉系统。肝素与溶栓药物联合应用疗效高于单纯使用溶栓药物。结论：血栓性病变的治疗应首先使用肝素抗凝,其次溶栓。溶栓必须和肝素抗凝联合,这是对血栓性疾病进行介入治疗的原则之一。     

Complications of intraarterial urokinase-lys-plasminogen infusion therapy in arterial ischemia of lower limbs

Thirty-five patients with peripheral arterial occlusions were treated by intraarterial infusion of low-dose urokinase associated with bolus of lys-plasminogen. Thrombolysis was achieved in 26 cases (74%), but only 10 patients (28.5%) experienced sustained improvement. Complications of thrombolysis occurred in 11 patients: Five patients developed groin hematoma, five had distal emboli, and one experienced macroscopic hematuria. Catheter-related thrombosis was observed in 14 patients (40%) despite intravenous heparin. Nine patients suffered from recurrent thrombosis and three from proximal emboli. A patient died from catheter-related infection. Limited fibrinolysis could increase pericatheter thrombosis, and further work will be necessary to assess the local risk of intraarterial thrombolysis.     

Updated Trends,Disparities, and Clinical Impact of Neuroimaging Utilization in Ischemic Stroke in the Medicare Population: 2012 to 2019

ObjectiveThe purpose of this study was to update trends, investigate sociodemographic disparities, and evaluate the impact on mortality of stroke neuroimaging across the United States from 2012 to 2019.MethodsRetrospective cohort study using CMS Medicare 5% Research Identifiable Files, representing consecutive ischemic stroke emergency department or hospitalized patients aged ≥65 years. A total of 85,547 stroke episodes with demographic and clinical information were analyzed using Cochran-Mantel-Haenszel tests and logistic regression. Outcome measures were neuroimaging (CT angiography [CTA], CT perfusion [CTP], MRI, MR angiography [MRA]) utilization, acute treatment (endovascular thrombectomy [EVT] and intravenous thrombolysis [IVT]), and mortality while in the hospital and at 30 days and 1 year post discharge.ResultsSignificantly increasing utilization trends for CTA (250%), CTP (428%) and MRI (18%), and a decreasing trend for MRA (?33%) were observed from 2012 to 2019 (P < .0001). Controlling for covariates in the logistic regression models, CTA and CTP were significantly associated with higher EVT and IVT utilization. Although CTA, MRI, and MRA were associated with lower mortality, CTP was associated with higher mortality post discharge. Less neuroimaging was performed in rural patients; older patients (≥80 years) had lower utilization of CTA, MRI, and MRA; female patients had lower rates of CTA; and Black patients had lower utilization of CTA and CTP.ConclusionsCTA and CTP utilization increased in the Medicare ischemic stroke population from 2012 to 2019 and both were associated with greater EVT and IVT use. However, disparities exist in neuroimaging utilization across all demographic groups, and further understanding of the root causes of these disparities will be crucial to achieving equity in stroke care.     

The radiological management of the thrombosed arteriovenous dialysis fistula

Patent vascular access is a prerequisite for adequate haemodialysis, and is a major determinant of quality of life and long-term survival of patients with end-stage renal disease. Autogenous haemodialysis fistulas (AVFs) have demonstrated superior clinical outcome when compared to synthetic grafts, but both types of access remain susceptible to venous stenoses, and consequent thrombotic occlusion. Recent publications have reported primary patency rates of up to 100% following percutaneous de-clotting of AVFs incorporating techniques such as pharmacological thrombolysis, mechanical thrombectomy, and thrombo-aspiration. Endovascular management also provides information regarding the underlying cause of access thrombosis, with option to treat. Consequently, there has been a paradigm shift in the management of fistula thrombosis, with interventional radiology assuming a lead role in initial salvage procedures. This article will attempt to provide the reader with an insight into the multiple radiological techniques that can be employed to salvage a thrombosed AVF based on current published literature.     

Treatment of acute ischemic stroke

Ischemic stroke is a medical emergency requiring fast and effective collaboration of neurologists and radiologists. Currently there are promising new developments in the treatment of acute ischemic stroke with efforts being made to reduce the door-to-needle time and to improve recanalization of occluded vessels by new endovascular techniques. Clinical trials have also demonstrated the efficacy of thrombolysis up to 4.5?h and confirmed the importance of the time to treatment for positive outcome.     

Akutbehandlung des isch?mischen Schlaganfalls

Ischemic stroke is a medical emergency requiring fast and effective collaboration of neurologists and radiologists. Currently there are promising new developments in the treatment of acute ischemic stroke with efforts being made to reduce the door-to-needle time and to improve recanalization of occluded vessels by new endovascular techniques. Clinical trials have also demonstrated the efficacy of thrombolysis up to 4.5?h and confirmed the importance of the time to treatment for positive outcome.